Like most CIOs in healthcare, Steve Hess has no shortage of things to do. First off, he’s knee-deep in a multi-year Epic implementation that will see him bid farewell to many incumbent vendors now, and more in the future. Secondly, he’s morphing the business side of the house from a best-of-breed environment to one concentrated on Lawson. And, as if that’s not enough, he’s working toward Meaningful Use while keeping a close eye on UCH’s ICD-10 conversion prep. To learn more about how Hess is juggling everything, healthsystemCIO.com editor Anthony Guerra recently caught up with the Denver-based CIO.
Working with a closed medical staff
CPOE in an AMC
MU attestation, complying with the letter of the law
A PQRI reprise?
Hess on Meaningful Use – “I think they’ve done a good job of lighting a fire”
From attestation to electronic reporting
Report fatigue on the way?
Epic at the UCH core
Vendors releasing upgrades in line with MU stages
The government wish list vs the customer wish list
Specialties and quality reporting
It’s not a black and white, CPOE-type of thing. You actually have to get down to the very specific type of orders and the specific workflows, and ambulatory and inpatient obviously work a little bit differently in terms of how things need to flow.
We’re creating some consistency across the hospital and around that independent practice plan, but the reality is there are going to be a lot of reports, and, I think, a lot of tweaking.
…meaningful use is always number one. And again, not only does it hold up the next release, but it also really de-prioritizes a lot of enhancements that we feel we need from an efficiency or maybe even a quality and safety perspective.
Guerra: Good morning, Steve. Thanks for taking some time to be with me today. I’m looking forward to our talk.
Guerra: Tell us a little about University of Colorado Hospital, the organization size, the scope, and we’ll go from there.
Hess: University of Colorado Hospital is an academic medical center, the only one in the Rocky Mountain region. It’s about 400 beds and growing. We recently moved to the Anschutz Medical Campus in Aurora, Colo., and share that space with the University of Colorado Denver School of Medicine, The Children’s Hospital of Denver, and soon the VA as well. It’s essentially a medical campus; a medical community right outside of Denver. It’s a growing organization. We have an expansion project on the book to expand several hundred beds, so we’re growing everyday. We’ve also taken on the enterprise EMR project with Epic so it’s a busy time.
Guerra: Are there any owned clinics or ambulatory centers?
Hess: Yes. We actually have quite a few ambulatory clinics scattered throughout the community—mostly in and around the Denver area—and we have some in Boulder and Highlands Ranch.
Guerra: So this clinic is far different from a physician practice office setup from an IT point of view.
Hess: No, not really. We have them connected through a network, obviously, but then they really just connect into our EMR similarly to how an independent physician practice would connect to a hosted EMR.
Guerra: Do you own some physician practices too?
Hess: They’re all essentially part of the University of Colorado Hospital umbrella. All of our faculty are staff within the University of Colorado Denver School of Medicine.
Guerra: It’s not like a community hospital where there are local independent physicians that refer patients?
Hess: No, they’re all affiliated.
Guerra: So it’s what you call closed system?
Hess: It is. You got it.
Guerra: You don’t have to deal with those independent businessmen that don’t want to listen to you?
Guerra: But I have heard that for people in closed systems, it’s not as easy as for some people in the community model. There’s a thinking that people will just do what they’re told because they’re employees. But in fact, you still have certain resistance that you have to work through, and they don’t just a march to your drum, correct?
Hess: Absolutely. You know physicians; they’re very different. Internal medicine physicians are very different than surgeons. And in addition, being part of academic medical center, there is a heavy focus on research and education, so we have essentially several hundred residents who rotate in and out of our hospital too. Residents from an IT perspective are usually pretty facile with the systems, and we don’t see them all the time. And that research component does have some complexity to what we’re trying to do within the hospital, so we’re not only serving our patient population within the hospital and our clinics, but we’re also serving our physicians from a research perspective. It’s complicated for sure, but in having the closed model, you do essentially have almost a fixed set of physician customers out there to work with.
Guerra: When I was listening to the ONC meetings, one of the areas being talked about was in terms of CPOE, can a resident do it or does have it to be the physician. They were saying that if it’s the resident or even a student, then the physician would not be the beneficiary of the CMS rules that might pop up in the warnings. Where’s the argument at this point in terms of CPOE with residents and students?
Hess: It’s not black and white; there are certain orders such as lab orders that the resident can essentially enter and sign off on. And then there are certain other orders like medication orders where it’s set up so that the residents actually enter the order, but essentially ping it for the attending to sign off. As it goes out to, let’s say, a retail pharmacy, the orders are actually going out under the attendant’s name. It’s not a black and white, CPOE-type of thing. You actually have to get down to the very specific type of orders and the specific workflows, and ambulatory and inpatient obviously work a little bit differently in terms of how things need to flow.
Guerra: In terms of what ONC or CMS is going to want with meaningful use reporting, do you think that in some of these areas you just have to make your best guess, and then you won’t know until you apply and they look at what you’re doing and say yes or no?
Hess: I think so. I think that the most important thing from my perspective around meaningful use is that you’re consistently measuring the outcomes and the metrics that CMS wants to see. For example, with your patient population, you have a choice of whether you actually, from an ED perspective, look at the outcomes for the folks that come to the ED and get discharged, versus those who come to the ED and actually get admitted. As long as you’re consistently measuring your outcomes and your data with a similar patient population, similar workflow, I think that’s where we’re all trying to get to. I think over the years as we get to the additional stages, there are always going to be clarifications and rulings on those clarifications to help us all. But I think every day—every week, there are additional FAQs and clarifications coming out that will help us figure out precisely what the intent of the regulations are.
Guerra: I had heard that one of the disappointments with the PQRI program was in how particular they were with the information coming in, and the fact that not a lot of money went to people that had made a good faith effort. Do you think it would be a big mistake for the government to go forward with this program because there is a lot of gray area and fuzziness? Do you think they should take good faith into consideration? Because if they’re looking for T’s that aren’t crossed and I’s that aren’t dotted and they start rejecting applications left and right, that’s not going to be good.
Hess: It’s a great question. Actually, it’s a tough question to answer. I think that in those cases where hospitals and physician practices have really tried to do the right thing—have put up the dollars and capital expense needed to implement a really solid EMR and have been able to get the adoption, get people on board, get the champions engaged and have really done a nice job—obviously, good faith should be rewarded in that case, because they’ve done everything right. Maybe they’re not getting precisely the outcomes that the federal government and others want, but they’ve done a great job, whereas I think there are some others that probably have spent a lot of money implementing the system, but really haven’t used it to its fullest capability. Depending upon how they actually report, they may or may not actually be achieving meaningful use, so it’s a gray area for sure. I think that as more and more folks actually achieve Stage 1, we’ll start to see really what that picture looks like and how those folks who have really tried to make a good faith effort and have done a nice job are getting rewarded or not. It’s going to be very interesting to watch.
I think that meaningful use, in itself, is a great thing. The intent is great. I think the way they’ve carved out Stage 1 and have lowered the bar slightly since the original draft metrics were released, they’ve really done a nice job in trying to light a fire under the healthcare IT industry to really get us moving. Stage 2, Stage 3, and beyond—I think that’s going to be challenging. They’re going to raise the bar, which is not a bad thing, but there’s always a concern about how quality metrics will be involved. Are they always going to pick the right things that really are focusing on quality and efficiency and so on? It’s going to be interesting to watch, but from a CIO perspective, I think the meaningful use is trying to hit the right target.
Guerra: Do you think we may see a big drop off between the adaptation phase and the electronic reporting, meaning that it’s easy to attest? I’m not saying people are going to be deceitful, but they might exaggerate some things a bit, and that could be far different from when the systems have to electronically submit. I can imagine there is much room for rounding the sharp corners. Do you think there will be a big difference between those two stages?
Hess: I hope none. What’s going to be interesting is that we’re very dependent upon our core vendors for the electronic reporting, so I think we might see a lot of client and vendor conversations where we think we’re in good shape, but the electronic reporting is telling different stories. So I think there’s going to be a lot of digging into how is that actual metric being measured. And in looking at some of the vendor provided reports, just essentially abandoning the vendor-provided electronic reporting reports and creating their own. I’m not sure there’s going to be a drop off, I certainly hope not, but I think there is going to be a lot of really digging into what are these reports doing and how they really measure them and some tweaking of those reports.
Guerra: I guess we want to make sure as an industry that we’re not spending incredible resources tweaking and drafting and doing reports.
Hess: Unfortunately, I think we’re going to, because at University of Colorado Hospital, we have a somewhat unique set-up in that our physicians obviously are part of University of Colorado Denver, but their billing is being done by a third party. So we’re sending a lot of our electronic medical record data and our professional billing data over to this third party, so they’re a partner of ours and partner of the physicians. We have this three-legged stool partnership, and we actually have to be able to produce data, using our EMR, so that they can individually attest at the eligible provider level. So we’re doing our best to try to create consistency around which of those objectives we’re going after, especially in that menu set. We don’t want to have a situation where one physician wants certain menu objectives and other physicians want other objectives. We’re creating some consistency across the hospital and around that independent practice plan, but the reality is there are going to be a lot of reports, and, I think, a lot of tweaking.
I think we’re in somewhat of a fortunate circumstance implementing Epic. I think Epic is a leader in the meaningful use space, and they’re doing a really nice job of helping their clients focus on where their gaps are; they’re doing data architecture or updates to accommodate meaningful use, and are producing really solid standardized reports. I think there are other vendors who are maybe a little bit further behind, and their clients are going to end up having to create their own one-off reports. The other interesting part is that the vendors—Epic included—are really looking at their release management strategies closely and linking them directly to meaningful use. So with a lot of their future developments focusing on meaningful use, they’re going to hold off with future releases until some of the criteria are actually finalized. It’s going to be interesting watching that because what it means is a lot of the vendors are going to be producing releases at similar times, and will have a lot of their clients need to upgrade very quickly to be able to make use of the meaningful use updates.
Meaningful use is not only changing the game in terms of where hospitals and physician practices are putting their energy; it’s dramatically changing the way the vendors are working as well.
Guerra: I interviewed John Glaser who, as you probably know, is heading up Siemens now, and he said that one of the inadvertent consequences of this is that the traditional customer wish list where vendors have a way to prioritize based on what the customers want are pretty much out the window. In most cases, there isn’t enough bandwidth to do the government’s wish, then the customer list, so the customer wish list suffers. Does that make sense?
Hess: Absolutely, and we’re seeing that. If you go to any vendor user group conference and you start talking to the development team about their priorities, I can tell you right now that meaningful use is always number one. And again, not only does it hold up the next release, but it also really de-prioritizes a lot of enhancements that we feel we need from an efficiency, or maybe even a quality and safety perspective. Meaningful use takes priority; it’s a game changer, for sure.
Guerra: How much frustration is there when you see these types of ramifications, even if you’re positive and you’re bullish on the whole program?
Hess: Well, I’m not overly frustrated. The one area—and this is more of a release management synchronization thing—is that our core vendor, Epic, is going to hold up their next release until Stage 2 is solidified. And we had a project rollout plan that was not counting on, but assuming that that next release would be available—the one we would take during our implementation, and now that’s not going to happen. It’s not a frustration; it’s just it changes your way of thinking. It changes your priorities, and for me, it’s just really interesting.
Guerra: It definitely is.
Hess: You have ICD-10 and some of these other big initiatives as well that are really changing people’s focus. But with meaningful use I think that even though we’re talking about the downsides of it, overall, it is a very positive thing. It created a little bit of the burning platform that healthcare IT really needed.
Guerra: You mentioned getting physicians on one set of core measures as opposed to having them all over the place, but what about specialties where a lot of objectives don’t apply, and now you’re going to have to do some customizing—is there a challenge around specialty physicians that is different?
Hess: There will be. I think for the most part, many of the objectives can be achieved across all of the different disciplines, but I do think there will be some specialty specific things, whether it’s a menu objective or a core objective, that really doesn’t apply to them, so it’s interesting. I think a lot of folks think of doctors as being the same, but an internal medicine doctor and an orthopedic surgeon are very different in terms of how they think, how they interact with the EMR, and how they interact with the patients. It’s very different out there, and that’s what makes healthcare IT so much fun—so challenging, but also so interesting.